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Editor's Note |

When Is It Better Not to Know Everything?

Rita F. Redberg, MD, MSc
JAMA Intern Med. 2014;174(6):852. doi:10.1001/jamainternmed.2014.652.
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This vignette illustrates an all-too-common problem—the incidentaloma—and one guaranteed to become more frequent because the US Preventive Services Task Force has just endorsed chest computed tomography for lung cancer screening, even beyond the population and frequency studied in the National Lung Screening Trial. It is critical to consider the price of our abundance of high-quality medical imaging. We need to seriously ponder our practice of following up on every incidental finding, no matter how unrelated to the presenting symptoms, with the recommendation of additional imaging and procedures. Fortunately, this patient “only” had 2 mild contrast reactions, which are uncomfortable, but one can expect a full recovery. Not all are so lucky. The more important question is what benefit could possibly come of working up all of these findings. Remembering our Less Is More principle, if there is no known benefit, all procedures and tests have some harms. For example, this patient received approximately 50 mSv of radiation (to convert to rems, multiply by 0.1), with the associated increased cancer risk.

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Less is More - Especially when you don't know what to do
Posted on April 15, 2014
John Rumberger, PhD, MD
Princeton Longevity Center, Princeton, NJ
Conflict of Interest: None Declared
I firmly agree that it is not necessary to chase after every abnormality noted on an imaging study or various blood tests - this must be interpreted in the context of the patient in front of you - many incidental findings are followed up because the doctor who is in charge does not know 'what to do'. For instance lung nodules below a certain size can be ignored - above a certain size requires only a repeat scan in times varying [depending on pre-test likelihood of a cancer] between 3 months and 12 months - there are papers and guidelines for these - but many clinicians do not know of these guidelines and most often the radiologist interpreting these tests does not want to say 'you don't need to follow this up' - thus the abnormality gets moved forward with a final result of 'never mind'.The problem however is that the physician is ignorant of what needs to be followed up and what does not need to be followed up - then we end up with the 'test' being blamed for the ignorance of the physician - who really 'does not know everything'.
I agree with Dr. Rumberger's comment, but....
Posted on May 16, 2014
David L. Keller, MD
none
Conflict of Interest: None Declared
For clinicians, there is too much to lose by not firmly establishing a diagnosis of \"benign\" for each incidental finding with the potential for being malignant. Primary care physicians rely primarily on their radiologist's report as authoritative advice on \"what to do\". I, too, have found that \"most often the radiologist interpreting these tests does not want to say 'you don't need to follow this up'\", which is an outright abdication of their duty as a consulting specialist, on the order of a cardiologist who reports an abnormality on an echocardiogram, but does not offer any advice on how to proceed. Radiologists need to assume their proper roles as consulting clinical specialists, offering the same quality and depth of information and guidance which a general internist expects from their consulting cardiologists, pulmonologists, nephrologists, etc.
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